In This Issue:

Informing Women about Misoprostol in Latin America

New Briefs on Abortion Access in the US

New Publications

NPR Story Features Ibis's Dan Grossman

Self-induced Abortion in US Webinar

Staff Updates

Dear Friend,

In this newsletter we are very pleased to highlight research we conducted with partners in Peru and Colombia on how to inform women about effective and safe use of misoprostol where abortion is legally restricted. The goal of the research is to identify language and pictures that will effectively communicate the key messages about misoprostol use, including the dose, expected side effects, and signs (very rare) that indicate the woman needs to seek medical attention. We will work with our partners to disseminate the materials to women across Latin America and the results of the research will help women minimize legal and health risks when self-inducing an abortion. Our work on misoprostol has also included development of web-based educational materials (www.medicationabortion.com) and analyses aimed at policymakers on how misoprostol can help reduce maternal morbidity and mortality around the world.

We are also excited to share recent publications from Ibis staff, including three articles in the most recent issue of Contraception, and two new Ibis resources from our work documenting the impact of the Hyde Amendment in the US on women and providers. We also encourage you to listen to a recent NPR story featuring our own Dan Grossman on anti-abortion groups’ efforts to restrict access to contraception and abortion by redefining when life begins. You can also listen to Dan and our colleagues in a recent webinar in which we shared the results of our study with Gynuity Health Projects on self-induced abortion among US women.

Thank you very much for your continued support and interest in our work! We welcome your questions and comments (admin@ibisreproductivehealth.org), and we look forward to sharing more news about Ibis’s work in the near future.

Warmly,

Kelly Blanchard, President

How to Inform Women about Effective and Safe Misoprostol Use:  A Study in Two Latin American Countries

Abortion is legally restricted throughout most of Latin America. Previous research suggests that women in this region are aware of and use misoprostol to self-induce abortions, but data also suggest that women do not have adequate information about the drug (Costa and Vessey 1993, Cohen et al. 2005, Lafaurie et al. 2005, Sherris et al. 2005). Use of ineffective regimens increases the risk of ongoing pregnancy or incomplete abortion, as well as unnecessary visits to hospitals. Therefore, educating women about misoprostol and what to expect with medication abortion is a critical part of helping women have safe abortions and minimize their health and legal risks.

In May 2010, Ibis launched a research project in collaboration with the Centro de Promoción y Defensa de los Derechos Sexuales y Reproductivos (PROMSEX) in Peru and with Fundación Oriéntame in Colombia to: 1) Assess women’s understanding of misoprostol use instructions contained in a pamphlet developed by the Latin American Consortium against Unsafe Abortion (Consorcio Latinoamericano contra el Aborto Inseguro, CLACAI) and 2) Evaluate women’s opinions about the pamphlet and how it can be improved.

We conducted 21 in-depth interviews (IDIs) and eight focus group discussions (FGDs) in the capital cities (Lima and Bogota) and in semi-urban areas (Cajamarca and Pereira) of Peru and Colombia, respectively. We recruited a convenience sample of women ages 18-45 through private and public clinics, universities, and women’s organizations. We stratified the FGDs by age of the participants (18-24 and 25-45 years old) and city (capitals and semi-urban cities). 

The pamphlet used in the study was designed in 2008 by CLACAI. It contains information about the gestational age limit for misoprostol use, dosage for vaginal and sublingual administration (both are highly effective), expected symptoms during the abortion process, what the woman should do after taking misoprostol, possible side effects, symptoms that require medical care, and what to do if misoprostol is not effective. All the information is presented in text and photos. It does not contain figures, drawings, or tables.

During IDIs and FGDs, we provided the pamphlet to each participant and gave them 15 minutes to read it. We evaluated comprehension and opinions of the written material through a series of questions asked by interviewers in IDIs and FGDs; in addition, FGD participants filled out a self-administered questionnaire. Women were allowed to look at the pamphlet while answering all questions.

Almost all participants expressed positive opinions about the pamphlet. In the questionnaire filled out by FGD participants, 95% reported that the pamphlet was easy to understand. In addition, the majority correctly answered most of the self-administered questions that evaluated their comprehension of the misoprostol instructions, including appropriate dosage, expected duration of bleeding, gestational age limit, and time at which bleeding and cramping would occur. However, only 35% correctly identified warning signs requiring medical care, including hemorrhage, allergic reaction, and severe pain. A lower proportion of women with less than 12 years of education, compared with women with 12 years of education or more, understood the correct gestational age limit to use misoprostol (85% vs. 100%, p<0.05) and the three warning signs that require medical care (38% vs. 66%, p<0.05).

Despite relatively good scores on self-administered questionnaires in the FGDs, FGD and IDI participants revealed problems with the presentation of the information on a number of topics. In all FGDs, the participants mentioned that the information about the dosage and administration of misoprostol was not clear and suggested improving this information by using tables and/or figures. The second most commonly mentioned concern was the feasibility of misoprostol use without professional supervision from a health care provider; many women expressed this concern because they believed women would not be able to self-assess eligibility for misoprostol use and legal restrictions on abortion in their countries would make it difficult to get misoprostol through pharmacies or health care providers. This last concern was expressed more frequently by young women.

Participants suggested adding information about women’s and health organizations, hotlines, and websites as complementary sources of information and emotional support and follow-up. Moreover, they expressed confusion about the different names of the drugs and recommended adding the commercial names of drugs that contain misoprostol that are available in each country. The findings of this study suggest that misoprostol educational materials should:

• Include tables, drawings, and other visual aids to make it easier to understand dosage and administration instructions,
• Emphasize that in the majority of the cases women are capable of self-inducing with misoprostol without professional supervision, while also being very clear about when clinical care should be sought,
• Provide lists of sources of information and care, especially in legally restrictive settings, and
• List commercial brands of misoprostol products that are available in the country.

We are now working in collaboration with CLACAI to improve the educational material and with PROMSEX and Fundación Oriéntame to disseminate the findings of our study. To see the CLACAI pamphlet used in the study, click here.

References

• Costa SH, Vessey MP. Misoprostol and illegal abortion in Rio de Janeiro Brazil. Lancet 1993; 341:1258-61.
• Cohen J, Ortiz O, Llaguno SE, Goodyear L, Billings D, Martinez I. Reaching women with instructions on misoprostol use in a Latin American Country. Reproductive Health Matters 2005; 13(26):84-92.
• Lafaurie MM, Grossman D, Troncoso E, Billings D, Chávez S. Women’s perspectives on medical abortion in Mexico, Colombia, Ecuador and Peru: A qualitative study. Reproductive Health Matters 2005; 13(26):75-83.
• Sherris J, Bingham A, Burns MA, Girvin S, Westley E, Gomez PI. Misoprostol use in developing countries: results from a multicountry study. Int J Gynaecol Obstet 2005; 88(1):76-81.

New Resources: Two Briefs on Abortion Access for US Women Enrolled in Medicaid

Ibis is pleased to announce two new briefs on abortion access for women who get their health care through Medicaid. The first brief focuses on Illinois, where a court order specifies that Medicaid funds cover all medically necessary abortions. However, Ibis’s research suggests that obtaining Medicaid coverage for abortion in Illinois is an extremely difficult and cumbersome process, leading to barriers for low-income women to obtain desired care.

The second brief outlines findings from interviews with close to 70 abortion providers in 15 states about their experiences obtaining state and federal Medicaid reimbursement for abortion care. Our findings show that in these states most women are unable to obtain federal Medicaid coverage for abortion, even when pregnancy is a result of rape or a threat to the life of the woman, bureaucratic Medicaid policies lead to delays in obtaining abortion care, and women and their families, providers, and abortion funds are paying for abortion procedures that legally should be covered by Medicaid. The brief concludes that the Hyde Amendment must be repealed to ensure that women enrolled in Medicaid have access to abortion services.

New Publications

We are pleased to announce a number of new peer-reviewed publications, including a supplement to the May-June issue of Women's Health Issues (WHI) celebrating the work of Ibis’s Ellertson Fellows, an exciting group of social scientists and public health researchers who study abortion and reproductive health and rights. The fellows were part of an innovative postdoctoral program, the Charlotte Ellertson Social Science Postdoctoral Fellowship in Abortion and Reproductive Health, which supported the development of a new generation of researchers dedicated to high quality research on abortion. The WHI supplement features 13 original articles, with contributions from every fellow that participated in the program (Read the full press release, forward by Wendy Chavkin and Kelly Blanchard, and supplement.)

In addition, three articles authored by Ibis staff were published in the most recent issue of Contraception. The articles address three priority areas of work at Ibis, including simplifying medication abortion, moving oral contraceptives over-the-counter in the US, and expanding the contraceptive method mix in South Africa. Please contact Ibis at admin@ibisreproductivehealth.org if you would like copies of these articles.

• Grossman D, Grindlay K. Alternatives to ultrasound for follow-up after medication abortion: a systematic review. Contraception 2011; 83(6):504-510.
• Liang S, Grossman D, Phillips K. Women's out of pocket expenditures and dispensing patterns for oral contraceptive pills between 1996 and 2006. Contraception 2011; 83(6):528-536.
• Blanchard K, Bostrom A, Montgomery E, van der Straten A, Lince N, Bruyn G, Grossman D, Chipato T, Ramjee G, Padian N. Contraception use and effectiveness among women in a trial of the diaphragm for HIV prevention. Contraception 2011; 83(6):556-563.

NPR’s Julie Rovner reports that anti-abortion groups such as Personhood USA are pushing to redefine life as beginning at fertilization and interviewed Dan Grossman, Ibis Senior Associate, for the story. Dr. Grossman stated that according to the accepted medical definition, pregnancy begins once the fertilized egg implants in the uterus, not at the time of fertilization. He further pointed out that only half of fertilized eggs become continuing pregnancies.

Dr. Grossman also discussed the implications of efforts to redefine life as beginning at fertilization for women’s health, noting that such efforts could restrict abortion as well as women’s contraceptive options by reclassifying a number of safe and effective birth control methods as abortifacients. Groups like Personhood USA are trying to get personhood ballots or referenda in a number of states this year in order to restrict women’s access to abortion and contraception.

To listen to or to read the full story, click here.